Welcome, Providers!

The following sections of the Fidelis Care authorization grids have been updated effective July 1, 2022.

The Essential Plan, Medicaid, Medicare and Metal-Level Products grids have been updated as follows:

            III. Outpatient surgery: The following services require prior authorization:    

E. Services for the following codes (10060, 11100, 11900 and 17000, 20600, 20605, and 20610) should not need to be performed in freestanding ambulatory surgery centers- If performed in freestanding ambulatory surgery centers billing with bill type 0831, they require an authorization.  CPT code 20610 for joint injection of hyaluronic acid is non-covered when billed with any of the following osteoarthritis diagnosis codes: M17.0, M17.10-M17.12, M17.2, M17.20-M17.32, M17.4, M17.5, M17.9.        

Pharmacy:

The following codes have been added to the Essential Plan, Medicaid, Medicare and Metal-Level Products authorization grids and require prior authorization:

C9094 sutimlimab-jome

C9095 tebentafusp-tebn

C9096 filgrastim-ayow (Releuko)

C9097 faricimab-svoa

C9098 Carvykti

J0219  avalglucosidase alfa-ngpt

J0491 anifrolumab-fnia

J0739  cabotegravir inj

J0879  difelikefalin

J1306  inclisiran inj

J1551  immune glob (Cutaquig)

J2356  tezepelumab-ekko (Tezspire)

J2779  ranibizumab implant (Susvimo)

J2998  plasminogen, human-tvmh (Ryplazim)

J3299  triamcinolone acetonide (Xipere)

J9071 cyclophosphamide (AuroMedics)

J9273 tisotumab vedotin-tftv

J9331  sirolimus protein-bound inj

J9332  efgartigimod alfa-fcab inj

J9359  loncastuximab tesirine-lpyl,

Q5124 ranibizumab-nuna (Byooviz)

The Medicare grid has been updated as follows:

VIII. Pharmacy                      

B.     Oncology medications and supportive agents will require prior authorization (PA) from New Century Health for all PARTICIPATING PROVIDERS before being dispensed at a pharmacy or administered in a physician’s office, outpatient hospital, or ambulatory setting for members 18 and over. PA can be requested by visiting NCH’s Web portal at my.newcenturyhealth.com or calling 1-888-999-7713, option 1.                  

                         For the list of drugs that require NCH review, please click on the following link:     

https://web-stg.fideliscare.org/Portals/0/Providers/New-Century-Health-NCH-Wellcare-By-Fidelis-Care-Medicare-Grid.pdf                     

C. Self-administered medications are covered under the pharmacy benefit. Self- administered medications are medications that are typically administered by a patient or caregiver, safely and effectively, without medical supervision or direct observation,              

D. The following injectable codes* that are not oncology related require authorization for both participating and non-participating providers (*Please see Medicare Authorization Grid for codes following this section.) 

Please submit prior authorization requests to our Pharmacy Team electronically via fax (e-fax) to: 1-877-882-5892 Please note, for oncology related requests by NON-PARTICIPATING providers will require authorization review by the Wellcare By Fidelis Care plan (fax to 1-877-882-5892)                   

The Medicaid grid has been updated as follows:

I.  Assertive Community Treatment (ACT) (adults and children): H0040                      

Requests for members can be made by email qhcmbh@fideliscare.org, fax (718) 896-1784 or by calling 1-888-FIDELIS (1-888-343-3547) and following the prompts for Behavioral Health                        

Visit:  Authorization Grids

COVID-19 UPDATE: Please refer to this link:  Important Updates Regarding Coronavirus COVID-19, for authorization and coding guidelines related to the COVID-19 Pandemic.